Lymphoscintigraphy and lymphedema of the lower extremities.

Lymphoscintigraphy, using technetium-99m-labeled sulphur microcolloid, was employed to study the flow and transport of lymph in the lower extremities of 39 consecutive patients in whom lymphedema of one or both legs was suspected clinically. Time-activity curves of four segments of each leg were evaluated for lymph capacity, flow and soft-tissue uptake, and compared with the results from film scintigraphy. Curve analysis provided quantitative evaluation of the extent of hypoplasia or aplasia in primary lymphedema and of lymphatic obstruction in secondary lymphedema, and is particularly suited to assess the involvement of lymphatics in chronic venous disease. Film scintigraphy, on the other hand, is preferable in cases in which the pattern of activity distribution in the affected extremity is diagnostic, such as in dermal back flow, traumatic lymphocele, or megalymphatics. Venography is most informative in cases of suspected underlying venous disease, but the role of lymphangiography, which shows only part of the lymphatic system and requires incision of the edematous tissues, is considered questionable.

Graded stress radiography of injured anterior cruciate ligaments.

Fifty-five patients with clinical suspicion of injury to their anterior cruciate ligament (ACL) were examined by graded stress radiography before arthroscopic verification in an effort to determine the loss of ACL function as a result of ligament tearing. Using a commercially available stress device capable of applying varying pressures to the mid-calf, anterior drawers were measured from lateral radiographs at 0-, 7-, 14-, and 21-kiloPascal pressures and used to calculate the equivalent elastic modulus of the remaining ACL fibers. According to viscoelastic theory, this modulus is proportional to the number of elastically active fibers in the ligament. To verify the validity of this concept, the stress-strain relationship of a freshly excised ACL ligament was examined in a tensile testing machine, and the procedure was repeated after the ligament had been partially transsected with a scalpel. Comparison with the elastic modulus of the (intact) ACL of the opposite knee permits an estimate of the percentage of rupture in cases of partial tears. Overstretched ligaments show essentially normal viscoelastic properties once the slack in the ligament has been taken up. Complete tears, on the other hand, show a complete breakdown in the viscoelastic properties of the ACL. The results show that partial tears can be diagnosed by graded stress radiography with a sensitivity of 20% and specificity of 90%. Diagnosis of overstretched ligaments had sensitivity of 50% and specificity of 94%. Complete tears were detected with sensitivity of 88% and specificity of 75% as diagnosed against all other ACL lesions and including normals.(ABSTRACT TRUNCATED AT 250 WORDS)

Injury to the lateral ankle ligaments of athletes. A posttraumatic followup.

Twenty of 26 original athletes with injuries to the lateral ligaments of the ankle were reexamined 2 to 5 years following treatment. The functional quality of their anterior talofibular (TF) and calcaneofibular (CF) ligaments was tested by stress examination, using a commercially available stress device, and was compared with the results of stress examination, arthrography, and surgery at the time of injury. Surgically treated patients showed a 70% to 100% recovery of the functional properties of the lateral ankle ligaments on comparison with the contralateral, uninjured ankle. Of the six patients treated conservatively with elastic bandages and rest, only one had regained normal function, whereas the others showed minimal or no improvement. Isolated lesions of the anterior TF ligaments, when treated conservatively, may have only a slightly better prognosis than a combined lesion of both anterior TF and CF ligaments in the athletic population.

Instrumented arthrometry for diagnosing partial versus complete anterior cruciate ligament tears.

Nineteen patients with the clinical diagnosis of anterior cruciate ligament injury were examined by KT-1000 arthrometry before arthroscopy in an effort to differentiate partial from complete tears. To this end, the KT-1000 arthrometer was equipped with a strain gauge and processor that permitted the required force to increase the anterior displacement by 1-mm increments, to be read on a light-emitting diode. The measured force has been plotted against anterior displacement expressed in non-linear increments along the x-axis to allow for the viscoelastic nature of the ligament. The results show that stress-strain diagrams of partially torn and completely torn ligaments are similar to those obtained by graded stress radiography. Using arthroscopy as the standard of measurement, partial tears can be differentiated from complete tears with a sensitivity of 80% and a specificity of 100%. The figures for complete tears versus partial tears are 100% and 80%, respectively. Graded arthrometry with x-y recording of the force-displacement relationship that allows for the viscoelastic qualities of ligament further extends the capabilities of instrumented arthrometry.

Magnetic resonance imaging of injury to the lateral ankle ligaments.

To establish the value of magnetic resonance imaging in determining which patients with ankle sprains will benefit from surgical treatment, 1 uninjured volunteer and 15 patients with acute, subacute, and chronic injuries of the lateral ankle ligaments were imaged at 1.0 tesla using a fast imaging with steady-state precision three-dimensional technique and 1.5-mm slice thickness. A dedicated knee coil was used to hold the foot in a neutral or plantar-flexed position. In cases of acute, low-grade injuries, fraying of the anterior talofibular ligaments with intact calcaneofibular ligaments was observed in the presence of edema and hemorrhagic fluid. In cases of acute, high-grade sprains, the calcaneofibular ligament appeared wavy or was visualized only partially or not at all. Subacute injuries showed ligament disruption; chronic lesions, on occasion, showed atrophy of the calcaneofibular ligament but no edema or hemorrhagic fluid. These findings showed a good qualitative correlation with the results of graded stress radiography. Magnetic resonance imaging can definitely determine the ligaments involved in lateral ankle sprains and provide useful anatomic information in cases in which acute or reconstructive surgery is contemplated. However, the magnetic resonance imaging findings do not directly correlate with degree of instability and do not replace those of physical examination or routine radiographic studies.

Shoulder pathoanatomy in marathon kayakers.

OBJECTIVES: To determine the prevalence of soft and hard tissue abnormalities and their interrelations in the shoulders of marathon kayakers and to examine the pathoanatomical factors that predispose these athletes to injury. METHODS: Fifty two long distance kayakers completed a questionnaire. Their shoulders were examined for range of motion, pain, and stability using a standard set of 10 clinical tests. The shoulder was subsequently scanned by magnetic resonance imaging (MRI) in three planes and evaluated for evidence of injury or other abnormality. The relation of clinical symptoms and MRI findings was investigated with respect to kayaker's age, number of years kayaking, and number of marathon races completed. RESULTS: Thirty subjects were asymptomatic at the time of scanning, and twenty two showed symptoms of pain and/or instability. MRI showed acromioclavicular hypertrophy, acromial or clavicular spur, supraspinatus tendinitis, and partial tear of the supraspinatus as the most common abnormalities. Kayaker's age, number of years kayaking, and number of races completed did not relate significantly to symptoms or to the presence of an abnormality on MRI scan. Of all the pathoanatomical findings that are reported to predispose to rotator cuff injury, only acromial and clavicular spurs were found to correlate highly with supraspinatus muscle pathology. CONCLUSIONS: Rotator cuff injuries make up a large portion of the injuries seen in marathon kayakers, about twice the number reported for sprint kayakers. These injuries are the result of secondary impingement factors associated with overuse, possibly specific to kayakers, and not the result of bony restrictions around the shoulder joint. Acromioclavicular hypertrophy is a common finding in marathon kayakers, but is possibly the result of portaging or a previous injury.

The effects of a functional elbow brace on medial joint stability: a case study.

Medical elbow ligament sprains in athletics can be traumatic and disabling. In this case report, we outline the effect of a prototype functional elbow brace on joint stability in a female collegiate javelin thrower with an ulnar collateral ligament sprain. A valgus force to both elbows was applied using graded stress radiography (Telos GA-II/E stress device) at 0, 5, 10, and 15 kiloPascals (kPa) of pressure. The increase in gap width between the coronoid process and the medial epicondyle was measured from anteroposterior radiographs to determine medial displacement. The brace resulted in less displacement in both injured and noninjured ulnar collateral ligament; injured ulnar collateral ligament demonstrated greater displacement regardless of condition. The brace restored medial stability to the elbow joint by 49%, 38%, and 35% at 5, 10, and 15 kPa of pressure, respectively. The application of the brace may be useful in athletes with ulnar collateral ligament injuries.

Graded stress radiography in acute injury to the lateral ligaments of the ankle.

The diagnostic accuracy of graded stress radiography in 26 patients with acute injury to the lateral ankle ligaments has been compared with findings at arthrography and surgery. Measuring talar tilt angles and anterior talar displacement over a range of pressures applied to the distal tibia using a commercially available stress device allows diagnostic distinction between isolated anterior talofibular ligament injury and a combined lesion that involves the calcaneofibular ligament. The results compare well with arthrographic and surgical findings.

Stress examination of traumatized lateral ligaments of the ankle.

In the diagnostic analysis of acute injury to the lateral ankle ligaments, ankle arthrography and plain film stress examination play an important role. Inasmuch as the treatment of choice, whether conservative or surgery, and insofar as the therapeutic results may be determined by the extent of injury, it is important to have access to quantitative information on the functional properties of the involved ligaments at the time of the initial diagnostic studies. This can be obtained by measuring the strain on the anterior talofibular (tf) and calcaneofibular (cf) ligaments as a function of pressure applied to the distal tibia. Any device that ensures that the externally applied pressure is proportionally carried through to the ligaments can be used for this purpose. The results of 25 quantitative stress examinations using a Telos stress device are compared with arthrography findings and findings at surgery. Stress examination correlates well with both arthrographic and operative findings. The method is also useful for the evaluation of chronic ankle instability, follow-up examinations, and for the detection of vestiges of previous trauma of the contralateral ankle. The procedure is straightforward and noninvasive and can be performed within 15 minutes.

Bilateral protrusio acetabuli in sickle cell anemia.

Extreme bilateral protrusio acetabuli is an unusual complication of hematologic disease. We have described a patient with sickle cell anemia who had this complication probably as a result of osteopenia. Thus sickle cell anemia should be added to the list of potential causes of protrusio acetabuli.

On the fate of methyl methacrylate in blood.

The fate of methyl methacrylate in fresh human blood was investigated in vitro by using gas chromatography. It was found that methyl methacrylate is present in cells in concentrations twice as large as in plasma, but it disappears exponentially with time at a rate that is at least 10 times faster than that in cells. The rate constant in cells is very small or even zero. The half-life of methyl methacrylate in whole blood is 3 hr at 20 degrees C. Gas chromatography is a convenient method for the rapid determination of methyl methacrylate levels in blood.

Stress examination of the cruciate ligaments: a radiologic Lachman test.

A commercially available stress device is described for the radiographic examination of the anterior and posterior drawer in patients with suspected injury to the cruciate ligament. The radiologic Lachman test correlates well with its clinical counterpart and with arthroscopy. Its specific advantages are quantitative documentation of the test results and the selective testing of the anterior and posterior ligaments.

Porous acrylic cement.

The use of acrylic bone cement has a number of shortcomings, viz., high curing temperatures that can cause thermal necrosis, release of toxic monomer, and a less than perfect cement-to-bone bond. However, by modifying the cement composition through the addition of a soluble, nontoxic filler such as sucrose or tricalcium phosphate which does not impair the workability of the material during surgery, a significant improvement in the performance of the cement can be achieved. Because the filler replaces part of the acrylic components, less heat is generated during curing while the filler itself acts as a heat sink. Also, less monomer, proportional to the amount replaced by the filler, diffuses from the implant site. Upon elution of the filler, a porous cement will be obtained provided that a critical minimum percentage loading is exceeded so that the filler crystals will make physical contact with each other. The value of this percentage depends on both crystal modification and size. In the 125-175 micron sucrose crystal size range, the critical minimum percentage lies in the range of 20-28 wt% loading. Above 30%, the interconnecting pore size increases sharply to a value which allows good tissue ingrowth into the pores. The introduction of filler and pores causes a drop in strength, but the diametral tensile strength of modified cement containing up to 40% pores and sucrose lies between .7 and 1.5 kg/mm2, respectively, which is still in the same range as that of bone.

A comparison between the diagnostic efficacy of 99mTc-MDP, 99mTc-DPD and 99mTc-HDP for the detection of bone metastases.

We have investigated the clinical efficacy for the detection of bone metastases of two recently marketed bone-seeking radiopharmaceuticals, HDP and DPD, compared with traditionally used MDP. Twenty patients received 15 mCi 99mTc-MDP; after assessment ten of these patients later received 15 mCi 99mTc-DPD and ten other patients of this group were injected with 15 mCi 99mTc-HDP. Scintigraphy took place 3 h after tracer injection. Quantitative analysis included the calculation of normal bone to soft tissue ratios, lesion to soft tissue ratios and lesion to normal bone ratios for all three radiopharmaceuticals. Visual inspection of the scintiphotos revealed the same number of bone lesions at the same localisations. Statistical evaluation of our quantitative data showed that the lesion to normal bone ratio was significantly higher for MDP than for DPD. No further significant differences in the uptake in normal bone or in the metastatic lesions were found between all three radiopharmaceuticals. It is concluded that the new bone-seeking agents DPD and HDP do not possess clinical advantages over MDP for the detection of skeletal metastases.

Computed tomography in Whipple disease.

A case of Whipple disease demonstrated on computed tomography (CT) a large mesenteric mass of low density and thickened folds in the jejunum, which was confirmed by barium studies. Retroperitoneal manifestations were absent. The importance of CT in demonstrating the extraintestinal manifestations of Whipple disease is emphasized.

Stress radiography of the medial elbow ligaments.

PURPOSE: To study the usefulness of stress radiography for evaluation of injury to the medial collateral ligament (MCL). MATERIALS AND METHODS: Forty-two injured athletes and four healthy athletes without symptoms underwent examination performed with a stress device. The increase in joint space width between the medial epicondyle and coronoid process, measured on anteroposterior radiographs obtained after 0 and 15 daN force was applied to the lateral elbow joint, was used to assess the extent of ligament tear. The validity of this technique was tested with study of selectively severed cadaveric MCLs. RESULTS: All complete and large partial tears were correctly diagnosed with stress radiography when the increase in joint space width was larger by 0.5 mm in the affected elbow compared with the opposite normal elbow. In subjects with values less than 0.5 mm, the MCLs were normal or showed a small tear that could be managed conservatively. CONCLUSION: Stress radiography of the MCL enables accurate diagnosis of large and complete tears and distinction between such tears and small partial tears and normal ligaments.